Does pulmonary artery catheter use change outcome? Yes.

This article discusses the advantages of pulmonary artery catheters, with emphasis on the Swan-Ganz catheter. Various studies and published reports confirming the efficacy of pulmonary artery catheter use are reviewed. In the author's opinion, it is evident that the Swan-Ganz catheter has withstood the test of time and scrutiny.

Splenic venous hypertension presenting as variceal hemorrhage caused by portal hypertension.

BACKGROUND: Splenic venous hypertension (SVH) may cause variceal hemorrhage that is clinically indistinguishable from similar bleeding caused by portal hypertension (PH). This may lead to erroneous treatment, including inappropriate portosystemic shunt placement. STUDY DESIGN: A retrospective review of 58 cases of variceal hemorrhage referred for transmesenteric variceal sclerotherapy and transvenous intrahepatic portosystemic shunt (TIPS) placement revealed that seven patients had SVH as a cause of bleeding, and required treatment other than TIPS. The role of medical imaging in the diagnosis and management of SVH was analyzed. RESULTS: Clinical data did not permit a differential diagnosis between PH and SVH as the cause of bleeding in all cases. Splenic venous hypertension was suspected and then confirmed exclusively by contrast-enhanced computed tomography (CT) and angiography, which are essential for correct patient management. CONCLUSIONS: Computed tomography should be routinely performed to exclude SVH before TIPS placement. In instances in which CT fails to establish the diagnosis or splenic artery occlusion is considered for patient management, angiography may be used.

The place for pneumoperitoneum in the repair of massive hernia.

Progressive pneumoperitoneum before the repair of massive abdominal and inguinal hernias, first introduced in 1940, remains an important technique in preparing patients for the operation. Reports of its use have appeared sporadically in the surgical literature. This article recounts the technique of progressive preoperative pneumoperitoneum, its advantages and complications, and the variety of situations in which it is useful. Surgeons treating large hernias accompanied by loss of domain of abdominal viscera should consider preoperative progressive pneumoperitoneum as a helpful and often necessary adjunct to hernial repair.

Functioning hepatic cell mass and the hyperdynamic state in cirrhosis.

Seventeen patients with advanced hepatic cirrhosis underwent cardiopulmonary assessment by means of Swan-Ganz catheters combined with indocyanine green clearance studies to measure functioning hepatic cell mass. The indocyanine green clearance test was found to have a statistically significant linear correlation with such indicators of the hyperdynamic circulatory state as cardiac index and total peripheral resistance. Results from these studies also showed that the hyperdynamic state in cirrhosis is associated with limited oxygen consumption as compared with a control series of patients. Of the 14 patients who required operations, eight survived and six died. The mean indocyanine green clearance was a statistically significant predictor of death.

Open chest cardiac massage: an overview.

Open-chest cardiopulmonary resuscitation has been shown to produce better blood flow in man than closed-chest massage. It therefore should be taught as part of the protocol for all hospital CPR teams.

Physiologic assessment of surgical diagnosis-related groups.

Although (diagnostic related groups) DRGs were originally devised as a research instrument for the evaluation of medical resource allocation, no studies have been reported that compare the actual physiologic status of patients with DRG classification. At the Westchester Medical Center, a University tertiary referral center, 100 consecutive high-risk elective surgical patients entered a preoperative intensive care unit for a prospective analysis of physiologic assessment, resource utilization, DRG classification, and outcome. Swan-Ganz catheters inserted 1 or 2 days before surgery were used to compute physiologic profiles and stage according to previously published criteria. Risk was determined by age, associated conditions, and magnitude of the proposed operation. There were no patients in stage 1; 55% in stage 2; 41% in stage 3; and 4% in stage 4, which accounted for three of the four total deaths. The 41% of patients over age 70 all had DRG comorbidity factors, but none died. All in stages 3 and 4 had comorbidity factors, as did 87% in stage 2. In 53% of the patients, the physiologic profile provided data necessary for preoperative "fine tuning"; in 37%, for volume expansion; in 23%, for inotropic therapy; and in 17%, for pulmonary therapy. Reoperation was required in 17% and contributed to the long average length of stay (LOS) of 24.5 days. In spite of case severity and comorbidity factors, LOS in the postoperative ICU was only 3 days. There were no significant differences in patients with cancer DRGs. Significant differences between stages 2 and 3 were found for pulmonary wedge pressure, right ventricular stroke work, pulmonary vascular resistance, and pulmonary shunt fraction. The 4% who died all had advanced liver disease. Although the DRG system as set up by the Health Care Financing Administration (HCFA) correctly predicts that age and comorbidity factors lead to increased utilization of resources, the extent to which they underestimate the increased needs of these patients will lead to financial disaster. Compensation for comorbidity factors and advanced age are not cumulative, but patients over 70 had an average of 2.5 comorbidity factors and required an average 26.5 days hospitalization. DRGs allowed only 15% extra reimbursement for these complex cases. High-risk, referred surgical patients are much sicker than they appear to the DRG system, and in all 100 cases compensation was grossly inadequate.

Update on the use of preoperative pneumoperitoneum prior to the repair of large hernias of the abdominal wall.

A review of eight repairs of large hernias of the abdomen pretreated with progressive artificial pneumoperitoneum is presented. Although three recurrences were noted during the follow-up period, two of the recurrences were repaired easily without further herniation. The advantages and complications of this procedure are discussed. Although the use of pneumoperitoneum prior to herniorrhaphy has been well described in the past, current emphasis on prosthetic mesh repairs has overshadowed its advantages. Progressive preoperative pneumoperitoneum as an adjunct to the repair of large abdominal hernias and eventrations should be part of the armamentarium of surgeons who are confronted with these difficult operative problems.

Preoperative assessment of high-risk surgical patients.

From the foregoing accounts of preoperative assessment of myocardial performance, as well as preload and afterload status it is clear that the proper anesthesia techniques and agents can be selected. Physiologically optimal adjustments of preload, afterload, and myocardial function can be attained by the appropriate, harmonious selection of anesthesia technique and vasoactive drugs made on the basis of close hemodynamic monitoring preoperatively, intraoperatively, and in the immediate postoperative period.

Assessment of nutritional and metabolic status of paraplegics.

Nutritional and metabolic assessment using anthropometric, biochemical, immunological, and indirect calorimetric techniques was performed on 17 healthy paraplegic males with a mean age of 44.2 +/- 14.6 years and mean duration of injury of 17.8 +/- 12.3 years. Significant differences in energy expenditure were observed; only 29.4 percent were normometabolic [measured resting energy expenditure: (MREE) 90-110 percent of predicted resting energy expenditure (PREE)], 35.3 percent were hypermetabolic (MREE greater than 110 percent of PREE) and 35.3 percent were hypometabolic (MREE less than 90 percent of PREE). Obesity (weight greater than 110 percent ideal body weight) was maximum in hypometabolic patients (83.3 percent) due to the imbalance between caloric intake and energy expenditure (p less than 0.05). None of the patients had normal values for all four objective measurements of nutritional assessment (albumin, transferrin, total lymphocyte count, and cutaneous hypersensitivity). Mild malnutrition was evidenced in 47 percent of patients; 53 percent of patients demonstrated some index of moderate malnutrition. We conclude that nutritional therapy based on measurements of energy expenditure instead of predictive equations will benefit these patients. A larger long-term study is needed to determine the ideal predictive measurements of nutritional assessment with their optimal cutoff values applicable to the spinal cord-injured patient.

Factors encouraging laparotomy in acalculous cholecystitis.

Because it is difficult to diagnose, acalculous cholecystitis in critically ill patients is treated frequently in an advanced stage. Three of 1600 cardiac surgery ICU admission cases and five of 500 general surgical ICU admission cases were analyzed retrospectively to determine which variables expedited diagnosis and might have encouraged earlier surgery. Vague right upper quadrant physical findings and nonspecific changes in liver function chemistries led frequently to radiologic evaluations. Noninvasive diagnostic procedures such as ultrasound and hepatobiliary scans were helpful but frequently inconclusive. Of the eight patients, the five survivors were diagnosed while still in the hyperdynamic hemodynamic state of early sepsis. Cholecystostomy performed early under local anesthesia was the safest procedure in this group of critically ill patients. After other sources of sepsis such as suppurative phlebitis, yeast septicemia, catheter sepsis, and other extra-abdominal sources such as soft-tissue, urinary, and pulmonary infections have been ruled out, hemodynamic data obtained from pulmonary artery catheters inserted during the early phase of sepsis increase diagnostic accuracy and should expedite surgical exploration.

Automated immune profile.

A simple means of evaluating the immune function of critically ill patients has been designed. This system uses 22 input data that are derived from an assessment of humoral and cellular immunity and of the various factors known to influence the immune status. The profile allows quantification of the degree of immune depression as well as follow-up of the progression of the immune status.

Systemic organ assessment using computerized profiles.

Clinical monitoring of isolated parameters may lead to erroneous conclusions or conflicting speculations about the patient's general physiological status. Data derived from two or three primary parameters may provide a better understanding of the patient's overall status. Four automated profiles have been designed to aid in the management of critically ill patients. Data obtained from simple blood and urinary tests are used to compute parameters for various physiologic, renal, respiratory, and metabolic functions. The derived data are plotted in hard-copy form. A sequential series of each profile assists the physician in making intelligent and rapid therapeutic decisions and in evaluating the effectiveness of this therapy.